Empirically Supported Therapies Research Articles

KEYNOTE: Three Positive Outcome TA Psychotherapy Cases: Hermeneutic Single-Case Efficacy Design Research in Action

The background to the research I have been involved in was my frustration with the dominance of CBT within statutory therapy services within the UK and a continued lack of recognition for TA. To me, as to most TA therapists, I could see in my day to day practice that TA was indeed an effective approach, but was afraid that that unless we as a community start to quickly accumulate research evidence supporting our convictions that TA would continue to be marginalised. As a result of an informal conversation with Professor John McLeod- a respected counselling and psychotherapy researcher- I was inspired to engage in research and to enrol with the University of Leicester to begin a PhD investigating the process and outcome of TA psychotherapy. I am now four years into my doctoral research, and have found it to be a deeply enriching experience which has brought me a great deal of personal and professional satisfaction. As my research has developed, I have become clearer in my vision and aim. My vision is to see TA recognised as an Empirically-Supported Therapy by the year 2020. This is an entirely realistic vision, and I hope that in reading this that many of you will be encouraged to join in and make this vision a reality. At this point, it is perhaps worth exploring a little bit about what research means to many within our community. My sense is that many of you will be able to identify with the following statement; ‘I know research is important… to help us to understand how therapy works, to improve how we do therapy, to contribute to our profession and to promote wider acceptance of TA and psychotherapy’ Is this true for you? I also suspect that many of you will be able to identify with the following statement; ‘My negative impression of research is that it… Isn’t for people like me, it is complex, boring and time consuming, it is not relevant to the practice of therapy and is an ethically dubious activity’ Is this statement true for you also? I would imagine that many of you will be able to identify with much of the second statement. I am basing my speculation about your views of research on some recent research which I conducted which investigated the perceptions that 16 TA psychotherapy trainees had of psychotherapy research. (for more information on the results of this research, see; Widdowson, M. (2012a). As I see it, if this second statement is common amongst members of the TA community, then unless this is addressed, the vision I described above will not become a reality. It is part of my intention in writing this article to highlight that research does not need to be complex, boring or time consuming, can be conducted by people like you and can produce findings which are highly relevant and applicable to the realities of the consulting room.

Solution-focused brief therapy to improve child well-being and family functioning outcomes with substance using parents in the child welfare system

This study examined the effectiveness of solution-focused brief therapy (SFBT) on child well-being and family functioning outcomes for child welfare involved parents. A randomized controlled trial design was used to evaluate the effectiveness of SFBT as compared to treatment-as-usual in an outpatient substance abuse treatment center. Mixed linear models tested within and between-group changes using intent-to-treat analysis ( N = 180). Hedges’s g effect sizes examined the magnitude of treatment effects. Both conditions reported improvements on the child well-being measures (Behavior Rating Inventory of Executive Function [BRIEF]-Parent Report and Child Behavior Checklist-School Age Form [CBCL-SA]) and family functioning measures (Adult-Adolescent Parenting Inventory [AAPI-2] and Center for Epidemiologic Studies-Depression [CES-D] Short Form) at posttest. While none of the between group analyses were statistically significant on either outcome domains, effect sizes did show improvements in the small to medium range for both groups. SFBT effect sizes for BRIEF subscales ranged from .024 to .267 and for control group ranged from .136 to .363. SFBT effect sizes on CBCL-SA subscales ranged from .059 to .321 and for control group ranged from .101 to .313. SFBT effect sizes on AAPI-2 subscales ranged from .006 to .620 and control group ranged from .023 to .624. SFBT effect sizes on CES-D measure were .428 and for control group were .317. Results show SFBT to be an effective intervention for helping parents around child well-being and family functioning outcomes similar to current empirically-supported therapies. SFBT provides a more strengths-based approach to help families improve family well-being and thus help improve their child’s well-being.

The effects of pilates on mental health outcomes: A meta-analysis of controlled trials

ObjectiveThis meta-analysis estimated the population effect size for Pilates effects on mental health outcomes. Data sourcesArticles published prior to August 2017 were located with searches of Pubmed, Medline, Cinahl, SportDiscus, Science Direct, PsychINFO, Web of Science, and Cochrane Controlled Trial Register using combinations of: Pilates, Pilates method, mental health, anxiety, and depression. Study selectionEight English-language publications that included allocation to a Pilates intervention or non-active control and a measure of anxiety and/or depressive symptoms at baseline and after the Pilates intervention were selected. Data extractionParticipant and intervention characteristics, anxiety and depressive symptoms and other mental health outcomes, including feelings of energy and fatigue and quality of life, were extracted. Hedges’ d effect sizes were computed, study quality was assessed, and random effects models estimated sampling error and population variance. Data synthesisPilates resulted in significant, large, heterogeneous reductions in depressive (Δ = 1.27, 95%CI: 0.44, 2.09; z = 3.02, p ≤ 0.003; N = 6, n = 261) and anxiety symptoms (Δ = 1.29, 95%CI: 0.24, 2.33; z = 2.40, p ≤ 0.02; N = 5, n = 231) and feelings of fatigue (Δ = 0.93, 95%CI: 0.21, 1.66; z = 2.52, p ≤ 0.012; N = 3, n = 161), and increases in feelings of energy (Δ = 1.49, 95%CI: 0.67, 2.30; z = 3.57, p < 0.001; N = 2, n = 116). ConclusionsThough this review included a small number of controlled trials with small sample sizes and non-active control conditions of variable quality, the available evidence reviewed here supports that Pilates improves mental health outcomes. Rigorously designed randomized controlled trials, including those that compare Pilates to other empirically-supported therapies, are needed to better understand Pilates’ clinical effectiveness and plausible mechanisms of effects.

The Effects of Resistance Exercise Training on Anxiety: A Meta-Analysis and Meta-Regression Analysis of Randomized Controlled Trials.

The salutary effects of resistance exercise training (RET) are well established, including increased strength and function; however, less is known regarding the effects of RET on mental health outcomes. Aerobic exercise has well-documented positive effects on anxiety, but a quantitative synthesis of RET effects on anxiety is needed. To estimate the population effect size for resistance exercise training (RET) effects on anxiety and to determine whether variables of logical, theoretical, and/or prior empirical relation to anxiety moderate the overall effect. Thirty-one effects were derived from 16 articles published before February 2017, located using Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. Trials involved 922 participants (mean age=43±21years, 68% female/32% male) and included both randomization to RET (n=486) or a non-active control condition (n=436), and a validated anxiety outcome measured at baseline, mid-, and/or post-intervention. Hedges' d effect sizes were computed and random effects models were used for all analyses. Meta-regression quantified the extent to which participant and trial characteristics moderated the mean effect. RET significantly reduced anxiety symptoms (Δ=0.31, 95% CI 0.17-0.44; z=4.43; p<0.001). Significant heterogeneity was not indicated (Q T(30)=40.5, p>0.09; I 2=28.3%, 95% CI 10.17-42.81); sampling error accounted for 77.7% of observed variance. Larger effects were found among healthy participants (Δ=0.50, 95% CI 0.22-0.78) compared to participants with a physical or mental illness (Δ=0.19, 95% CI 0.06-0.31, z=2.16, p<0.04). Effect sizes did not significantly vary according to sex (β=-0.31), age (β=-0.10), control condition (β=0.08), program length (β=0.07), session duration (β=0.08), frequency (β=-0.10), intensity (β=-0.18), anxiety recall time frame (β=0.21), or whether strength significantly improved (β=0.19) (all p≥0.06). RET significantly improves anxiety symptoms among both healthy participants and participants with a physical or mental illness. Improvements were not moderated by sex, or based on features of RET. Future trials should compare RET to other empirically-supported therapies for anxiety.

Monitoring the Counseling Relationship and Client Progress as Alternatives to Prescriptive Empirically Supported Therapies

Many insurance companies and professional organizations have increasingly stipulated that mental health professionals use interventions that have been classified as empirically supported therapies (ESTs). Though the EST movement aims to provide clinicians with straightforward, evidence-based interventions for making treatment planning decisions, there are several practical and scientific barriers to the wholesale implementation of ESTs by mental health counselors. These barriers will be discussed, and two alternative strategies—cultivation of the counseling relationship and routine outcomes monitoring—will be presented as evidence-based alternatives to prescriptive ESTs.

The Emotional and Functional Impact of the Type of Tinnitus Sensation.

One to three percent of individuals with tinnitus experience significant reduction in quality of life. Factors that contribute to distress include personality variables, intolerance to loud noises, external locus of control, and pre-existing anxiety. Characteristics of tinnitus itself, such as perceived loudness, can also cause functional impairment. It is unknown whether different tinnitus sensations have various effects on either emotional or functional impairment, which can reduce quality of life. While audiological tests can determine pitch and loudness of tinnitus, questionnaires also can be easily used to assess subjective characteristics of tinnitus. In this study, 370 participants, recruited via email from a national tinnitus organization, completed online surveys that assessed tinnitus-related distress and provided qualitative descriptions of their tinnitus sensation. Self-reports of tinnitus sensation were rated by five independent coders, with excellent agreement. Individuals who reported a combination of tinnitus sensations were found to experience significantly more functional impairment and avoidant behavior. Future research should utilize more sophisticated approaches to categorize individuals' tinnitus sensation and to examine associated emotional and functional differences. Providers should appropriately refer patients for tinnitus management and empirically-supported therapies aimed at reducing tinnitus related distress and functional impairment.

Annual Research Review: Building a science of personalized intervention for youth mental health.

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health. The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics. The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

Limitations of Randomized Control Designs in Psychotherapy Research

Despite the growing influence of lists of empirically supported therapies (ESTs) there are concerns about the design and conduct of this body of research. These concerns include limitations inherent in the requirements of randomized control trials (RCTs) that favor those psychotherapies that define problems and outcome in terms of uncomplicated symptoms. Additional concerns have to do with criteria for patient selection, lack of integration with research on psychotherapy process and effectiveness studies, limited outcome criteria, and lack of controls for experimenter bias. RCT designs have an important place in outcome research; however it is important to recognize that these designs also place restrictions on what and how psychotherapy can be studied. There is a need for large scale psychotherapy outcome research based on designs that allow for inclusion of process variables and the study of the effects of those idiographic approaches to therapy that do not lend themselves to RCT designs. Interpretative phenomenological analysis may provide a useful method for the evaluation of the effectiveness of idiographic approaches to psychotherapy where outcome is not understood solely in terms of symptom reduction.

Controversies in Psychotherapy Research: Epistemic Differences in Assumptions about Human Psychology

It is the thesis of this paper that differences in philosophical assumptions about the subject matter and treatment methods of psychotherapy have contributed to disagreements about the external validity of empirically supported therapies (ESTs). These differences are evident in the theories that are the basis for both the design and interpretation of recent psychotherapy efficacy studies. The natural science model, as applied to psychotherapy outcome research, transforms the constitutive features of the study subject in a reciprocal manner so that problems, treatments, and indicators of effectiveness are limited to what can be directly observed. Meaning-based approaches to therapy emphasize processes and changes that do not lend themselves to experimental study. Hermeneutic philosophy provides a supplemental model to establishing validity in those instances where outcome indicators do not lend themselves to direct observation and measurement and require "deep" interpretation. Hermeneutics allows for a broadening of psychological study that allows one to establish a form of validity that is applicable when constructs do not refer to things that literally "exist" in nature. From a hermeneutic perspective the changes that occur in meaning-based therapies must be understood and evaluated on the manner in which they are applied to new situations, the logical ordering and harmony of the parts with the theoretical whole, and the capability of convincing experts and patients that the interpretation can stand up against other ways of understanding. Adoption of this approach often is necessary to competently evaluate the effectiveness of meaning-based therapies.

Novel Unsupported and Empirically Supported Therapies: Patterns of Usage Among Licensed Clinical Social Workers

While considerable attention has been focused in recent years on evidence-based practice, less attention has been placed on clinical social workers' choice to use ineffective or harmful interventions, referred to in the present paper as Novel Unsupported Therapies (NUSTs). The present study surveyed 400 Licensed Clinical Social Workers (LCSWs) across the United States in order to determine the extent of their usage of NUSTs, as well as their usage of conventional therapies that lacked support and empirically supported therapies (ESTs). Reasons for selecting interventions were also assessed. While the vast majority (97.5%) reported using some form of EST, 75% of our sample also reported using at least one NUST. Logistic regression analysis revealed that NUST usage was related to female gender and trauma specialization. A split plot ANOVA revealed that respondents rated positive clinical experience higher than published research as a reason for selecting an intervention. LCSWs with a CBT theoretical orientation rated research evidence more highly than those of other theoretical orientations. However, even within the group of LCSWs with a CBT orientation, clinical experience was rated more highly than research evidence. Implications for practice are discussed.

A Vision of the Next Generation of Behavioral Therapies Research in the Addictions

Whither, or wither, empirically supported therapies? Increasingly rigorous research in behavioral therapies has yielded a large number of effective therapies, but comparatively little work, demonstrating that integrating empirically supported therapies (ESTs) into standard practice results in meaningful improvements in patient outcomes. Methodology and strategies for evaluating ESTs and their effectiveness in clinical practice is a fairly recent innovation, and a host of unanswered questions remain regarding issues such as selection among different ESTs and what type of ESTs should be emphasized in dissemination efforts, what type of clinicians should be trained in what type of ESTs, the most effective training strategies for various types of clinicians, the need for ongoing supervision to maintain minimum levels of treatment fidelity and skill. In this review, we call for broader use of new research strategies and methods relevant to dissemination of ESTs; these may include adaptive designs, identificati...

Braking the Bandwagon: Scrutinizing the Science and Politics of Empirically Supported Therapies

ABSTRACT Proponents of empirically supported therapies (ESTs) argue that because manualized ESTs have demonstrated efficacy in treating a range of psychological disorders, they should be the treatments of choice. In this article, the author uses a hypothetical treatment for obesity to highlight numerous flaws in EST logic and argues for common factors as a more clinically relevant but empirically challenging approach. The author then explores how political variables may be contributing to the expansion of EST and the resulting restriction of practitioner autonomy. Last, the author argues that EST is best viewed as 1 component of a more comprehensive evidence-based practice framework. The author concludes with some cautionary statements about the perils of equating the EST paradigm with the scientist–practitioner ideal.

Influential psychotherapy figures, authors, and books: An Internet survey of over 2,000 psychotherapists.

In a partial replication and extension of a survey conducted 25 years ago (Smith, 1982), over 2,400 North American psychotherapists completed a Web-based survey in which they identified prominent figures in the psychotherapy field who have most influenced their practice and the best psychotherapy books they had read in the past 3 years. There is a continued prominence to leaders of the field from 25 years ago but who are now deceased, notably the top-ranked Carl Rogers. Three books on the top-10 list represent empirically supported therapies (ESTs); two are treatment manuals for an EST, and one is a self-help book derived from an EST that has itself been shown to be efficacious bibliotherapy. Differences between psychologist and nonpsychologist therapists in the choice of influential figures, authors, and books are negligible. Implications are discussed in terms of the contemporary context into which therapeutic innovations are disseminated, as well as the conditions that may be necessary for successful dissemination. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Review of The case formulation approach to cognitive-behavior therapy.

Reviews the book, The case formulation approach to cognitive-behavior therapy by Jacqueline B. Persons (see record 2008-13011-000). This book places case formulation as its core organizing principle for cognitive-behavior therapy (CBT). Explicitly framing case formulation in a hypothesis-testing context, Persons helps bridge the gap between those advocating strict adherence to manual-driven, empirically supported therapies (ESTs) and those who find such constraints impractical and less than optimal. Her guiding principle is to use ESTs to the extent that one can but to adapt them idiographically as one must to address the array of problems presented by the specific individual being treated. Persons' case formulation model is deceptively simple. It involves four basic components: (a) symptoms, disorders, and problems; (b) mechanisms; (c) precipitants; and (d) the origins of the mechanisms. Persons provides a fresh outlook on all these familiar components. In addition to providing step-by-step instruction for developing the formulation, Persons includes discussions of goal setting, which is organized in categories focused on mechanism change or learning compensatory strategies; treatment plan development; monitoring progress; decision making in the session; and handling nonadherence and treatment failure. A major strength of the book is the focus on the patient-therapist relationship. Persons repeatedly returns to the importance of establishing a positive working alliance and also discusses the opportunities that arise in efforts to re-establish a positive alliance following a rupture. The book is well organized, clearly written, contains up-to-date research references, and is replete with clinical examples. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Training in Cognitive Behavioral Therapy in Psychiatry Residency

In January 2001, Accreditation Council of Graduate Medical Education accredited general psychiatry training programs were charged with the requirement to train residents in cognitive-behavioral therapy (CBT) to a level of competence. Programs were given the responsibility to delineate standards for trainees, to determine measures of competence, and to provide remediation for deficiencies in performance. Effective education in CBT in general and child and adolescent psychiatry residency training can be more successful when educators understand the barriers to implementation of empirically supported therapies (ESTs). Robust training programs in CBT must take into account cultural barriers to psychotherapy training and the educational demands placed on residents in adult and child and adolescent psychiatry. Resources for training and evaluation materials are available to training directors and teachers.

What is usual about “treatment-as-usual”? Data from two multisite effectiveness trials

Despite increased emphasis on broadening the implementation of empirically supported therapies (ESTs) to improve standard clinical practice and patient outcomes, objective descriptions of what actually constitutes standard practice in community-based drug abuse treatment do not exist. We present data from independent ratings of 379 audiotapes drawn from the “treatment-as-usual” arm of two multisite randomized effectiveness trials in the National Institute on Drug Abuse Clinical Trials Network. As expected, the most frequently occurring strategies involved assessing the participant's substance use and social functioning, asking open-ended questions, discussing problems and feedback, and giving advice and direction. However, a number of interventions associated with ESTs were very rarely implemented in these early sessions. These data suggest missed opportunities for optimally engaging patients in the early stages of treatment and enhancing substance use outcomes and only moderate success to date of efforts to bridge the gap between research and practice.

Strategic Eclecticism in Hypnotherapy: Effectiveness Research Considerations

Hypnosis is attempting to come to grips with the EST (Empirically Supported Therapy) revolution in mental health practice. However, there are ways to account for outcome outside of simple empirical validation of treatment models. In this light, strategic eclecticism as a broader research-based consideration is used to illustrate empirical principles within Eriksonian hypnotherapeutic approaches.

W(H)ITHER EMPIRICALLY SUPPORTED THERAPIES (ESTS)? REPLY TO COMMENTARIES

W(H)ITHER EMPIRICALLY SUPPORTED THERAPIES (ESTS)? REPLY TO COMMENTARIES

A vision of the next generation of behavioral therapies research in the addictions*

Whither, or wither, empirically supported therapies? Increasingly rigorous research in behavioral therapies has yielded a large number of effective therapies, but comparatively little work, demonstrating that integrating empirically supported therapies (ESTs) into standard practice results in meaningful improvements in patient outcomes. Methodology and strategies for evaluating ESTs and their effectiveness in clinical practice is a fairly recent innovation, and a host of unanswered questions remain regarding issues such as selection among different ESTs and what type of ESTs should be emphasized in dissemination efforts, what type of clinicians should be trained in what type of ESTs, the most effective training strategies for various types of clinicians, the need for ongoing supervision to maintain minimum levels of treatment fidelity and skill. In this review, we call for broader use of new research strategies and methods relevant to dissemination of ESTs; these may include adaptive designs, identification of mechanisms of action to foster greater emphasis on effective change principles, training and adoption trials, as well as novel implementation strategies including computer-assisted therapy and computer-assisted training.

Providers’ and payers’ endorsements of empirically supported therapy: A power–knowledge relationship?

Abstract The promotion of empirically supported therapies (ESTs) has been prompted in part by the need to meet perceived demands of 3rd-party payers. Yet little communication has occurred between psychologists and payers as to how decisions regarding treatment are made. In this study, providers of psychological treatment and representatives of the insurance industry were interviewed about their views on this topic. Transcriptions of the interviews were analyzed using an approach derived from the grounded-theory method. In addition to the expected influence by payers on providers for lowered costs and “objective” outcomes, it was evident that both payers and providers were influenced by providers’ promotion of cognitive–behavior therapy as an EST. The respective practices of providers and payers were interpreted to constitute a complex matrix of joint influence. In light of the literature suggesting little compelling evidence for the exclusionary claims made for ESTs, the relevance of Foucault's notions re...